57 - Endovascular Repair of a Ruptured Mycotic Aneurysm Involving the Descending Thoracic Aorta
M. Noor, D. Chang, E. Bivins, J. Bermudez, D. Varnagy
Purpose: To describe a case of an endovascular repair of a ruptured infected thoracic aortic aneurysm and to provide a review of the current literature involving treatment.
Material and Methods: A 64-year-old female with a history of essential thrombocytosis, chronic portal & splenic vein occlusion, and DVT on Coumadin, presented with subjective fevers, nausea/vomiting, and mid-back pain. She was diagnosed with pneumonia and started on antibiotics. CT obtained on hospital day (HD) 2 demonstrated a large 6.4 cm irregular saccular aneurysm vs. pseudoaneurysm of the distal descending thoracic aorta. Due to hemodynamic and respiratory deterioration, a second CT chest on HD 5 demonstrated enlargement and further irregularity of the thoracic aneurysm and worsening pleural effusions. Significant peri-aortic inflammatory changes and persistent leukocytosis brought up the concern of a possible ruptured mycotic aneurysm. Patient was deemed a poor surgical candidate and underwent an emergent endovascular repair with plans for explantation and open repair once stabilized.
We will further discuss the procedure in detail with a pictorial review.
Results: Infected aortic aneurysms are associated with significant morbidity and mortality. Risk factors for the development of infected aneurysms include antecedent infections, immunosuppression, atherosclerosis, and pre-existing aneurysms. While bacterial translocation is rare, it may occur due to septic emboli of the vasa vasorum, direct inoculation, or contiguous infections. Clinical presentation is usually vague, and imaging is usually required for diagnosis. Blood cultures should be obtained, however, may be negative in 25-50% of cases (as in this case). CT angiography findings suggesting an infected aneurysm include an irregular aneurysm, peri-aortic inflammation, consolidation, fluid collection, and intramural air. While no randomized control trials have been conducted to guide the treatment of infected aortic aneurysms, general considerations include antibiotics and surgical debridement, aneurysmal excision, and reconstruction. Endovascular repair has been gaining popularity in recent years and is reserved for high-risk patients or those with aneurysm rupture as a temporizing measure.
Conclusions: Endovascular aortic repair is indicated as a temporizing measure for ruptured infected aneurysms or in patients with an infected aneurysm who are not candidates for open repair.